I am seeing patients one day and come to a room with a chart in the door which says “Post vasectomy.” I note that the patient had had a vasectomy by me about several years prior to this visit.

I enter the room and there I see a husband and wife and the husband is holding a newborn baby. Only a urologist can really know how it feels to be told of a possibility of a patient having a child after you did the vasectomy. It is not a good feeling…like all the blood goes to your feet feeling.

I ask, “I did your vasectomy?”

The husband says, “Yes”

I say, “Is that y’all’s baby.”

The couple smiles and beaming in unison say, “Yes”

There is a pause. I don’t know really what to say. I was about to say, “I’m sorry. You know there is a one in 2000 chance of these tubes growing back together.”

The wife says, “We are here for a vasectomy.”

Aside: I have had pregnancies after a vasectomy in career about 5 times. Usually it is because the male did not assure sterility by bringing a specimen to the office to be checked. More commonly the couple will have sex too soon after the vasectomy assuming that “If I had a vasectomy then there are no sperm.” They forget that it takes approximately thirty ejaculations to clear the sperm after a properly performed vasectomy. So sex before the sperms clears can cause pregnancy as the sperm is beyond the vasectomy site of occlusion. So even though the urologist never wants to hear about pregnancy after the vasectomy, most commonly it is not because the vasectomy was not performed properly.

Aside 2: It is also common that when a couple has a child after a vasectomy, for whatever the reason, they are happy or shall I say not disappointed about it. Some will say, “It’s God’s will.” By the tone of the conversation with the referenced couple, I felt that they were happy to have a had a child and that were not angry at me nor blaming me for anything.

Where was I? Anyway I say, “I am sorry about this. You came to me for the vasectomy because you did not want anymore children. Regardless of the cause I apologize and will happily do the vasectomy at no charge.”

The couple appears surprised and the wife says, “We wanted a baby.”

I am relieved and the blood in body is beginning to circulate to my upper extremities again.

Another pause and now the couple appears confused.

The wife says, “Doctor McHugh, there is no reason for an apology. We are very happy.”

The husband says, “Remember…you did my vasectomy reversal last year. We just had this beautiful baby and now I want a vasectomy.” The nurse had failed to put the most recent note in the chart of this patient which would have let me know this patient had had a reversal.

So…I do the vasectomy.

A vasectomy, a reversal and baby, and then another vasectomy. A urological vas deferns “Hat trick.”

A lot of couples debate which of the two major methods of having a child after vasectomy they should pursue. Often times it is a decision based on cost. For that couple wanting to do IVF first, this study shows no significant scarring as a result of the aspiration and no significant negative effect to a successful vasectomy reversal.

Background: 4% to 6% of men consider having children after vasectomy. Choices are either vasectomy reversal or sperm aspiration for in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI). Percutaneous sperm aspiration (PESA) is one way for sperm retrieval, but the degree of epididymal damage is unknown. The request for microsurgical reconstruction after failed PESA is limited.

Objective: To investigate the ability to perform vasectomy reversal after failed PESA-IVF-ICSI. Design: Retrospective study involving a specialized subset of patients who requested and underwent a vasectomy reversal after PESA. Participants: 8 patients who failed 1 to 4 attempts at IVF-ICSI with sperm retrieved by PESA. Methods: Patients were identified from the records of 3 experienced infertility microsurgeons. The side of the PESA was determined. Vasovasostomy (VV) or vasoepididymostomy (VE) was performed based on standard of care–intraoperative fluid from the testicular end of the vas. Two-layer VV or end-to-side/2-stitch VE was performed. Postoperative semen analysis was performed at 3-month intervals. Results: All patients had bilateral PESAs performed. Of the 8 patients, 4 had no apparent abnormality to the caput of the epididymis, 2 had small blue cysts at the caput, and 2 had small areas (<0.5 cm) that appeared necrotic or ischemic. No specific puncture site for the PESA could be seen at the time of reconstruction. Ten of 16 vasal units had sperm in the testicular end of the vas at the time of vasectomy reversal. Six of 16 vasal units had pasty fluid and required VE, and 1 patient had a bilateral VE. The time from vasectomy was from 15 to 22 years. All patients postoperatively had sperm in the ejaculate from 1 to 200 million/cc, with 15% to 90% motility. Surgery resulted in 4 pregnancies leading to deliveries. Conclusions: PESA caused only limited trauma to the epididymis with 87.5% of patients able to have a vasovasostomy on at least one side.Vasoepididymostomy was more likely related to the duration from vasectomy than due to scarring from PESA. Reviewer’s Comments: This paper reports on an important question about a simple percutaneous procedure to retrieve sperm for IVF-ICSI. A select group of men will want to undergo vasectomy reversal after a failed IVF-ICSI cycle. This paper answers the concern about possible scarring from PESA–it does not appear to. The technique did not differ in outcome despite 3 different surgeons involved for both PESA and reversals. The study is, of course, limited by the small number, but this surgery is not performed very often. The ability to bypass/avoid scarring at the epididymis may be related to several ducts coming from the rete testes to become efferent ducts before becoming a single tubule. The caput is often the target for PESA; therefore, if any scarring occurs, then the other efferent ducts may provide sperm down the epididymis. (Reviewer–Ajay K. Nangia, MBBS).

The First Few Days

During the first couple of days after surgery, you may experience slight swelling or bruising in the scrotum. In addition, the surgery and anesthesia could cause a headache, general pain, and nausea, among other short-lived side effects.

To soothe the scrotal area and help minimize swelling during the first few days, you’ll need to elevate your legs, stay off your feet, and use ice packs. You’ll need to avoid submerging the incision in water fort he first 48 hours after the procedure–showers after a day or so are just fine but avoid baths and swimming, both of which increase the risk of infection. Your surgeon will also give you a course of antibiotics to prevent infection.

Contact your doctor immediately if you have sudden chills or fever, swelling or pain that gets worse, or drainage from the site of surgery. These are all potential signs of infection.

The First Few Weeks

After a vasectomy reversal, you will gradually be able to return to your previous physical activities, typically over the course of three to four weeks.

Within a week or so you should be able to return to work and handle most of your normal routine, but you’ll want to avoid major physical activity for two to three weeks. This includes heavy lifting, working out, and excessive walking or driving.

You should also be able to resume sexual activity within two to three weeks; the procedure should have no effect on your sex drive nor your ability to have an erection or orgasm.

Pregnancy after Reversal

Your doctor will begin checking for the presence of sperm in your semen after one or two months, and will continue testing periodically until sperm have reached acceptable levels. It’s normal for sperm to take several months to appear in ejaculate, and it can sometimes take up to 15 months for them to return.

One way in which the success of a vasectomy reversal is measured is sperm count and sperm motility. Both of these may not return to a normal range for three to six months. Overall, 92 percent of vasectomy reversals result in sperm returning to the semen.

The ultimate test for whether a reversal has been successful, however, is pregnancy, which can sometimes occur as quickly as a few months after the procedure or as long as several years later. Roughly 30 to 60 percent of vasectomy reversals ultimately lead to natural pregnancies, and over half result in pregnancy within two years.

Background: The examination of the vasal fluid at the time of vasectomy reversal has implications for surgical decision making with effects on patency and pregnancy rates. The Silber grading system characterizes these findings and has been used to help surgeons with the decision to perform vasovasostomy (VV) or the more technically challenging vasoepididymostomy (VE).

Objective: To determine both intraoperative and patient factors that affect pregnancy rates after vasectomy reversal.

Design: Retrospective review of prospectively maintained database.

Methods: This paper reviewed the results of a single surgeon series that encompassed >30 years of vasectomy reversals. Vasal fluid was characterized as opalescent, creamy, pasty or clear and intraoperative light microscopy was used determined if sperm parts were present or motile. Univariate and multivariate analysis examined the data set for significant factors that affected pregnancy rates.

Results: 2947 vasectomy reversals were included in the analysis. Pregnancy status was only known for 31% of these cases. Bilateral VV was performed 83% of the time and most patients fell into a Silber 1 to 3 classification. No factors met statistical significance for increasing the pregnancy rate, although the presence of motile sperm was almost significant (P =0.075).

Negative predictive factors for pregnancy were identified on multivariate analysis with increasing female age and the findings of either no sperm (odds ratio [OR], 0.08) or sperm heads only (OR, 0.46) on microscopy decreasing pregnancy rates. Rarely were sperm parts identified when pasty fluid was encountered.

Conclusions: The findings from this paper echo the findings of the Vasovasostomy study group, with the Silber grading system essentially dictating pregnancy rates.

Reviewer’s Comments: The decision to perform VV or VE can be a difficult one and is based on many factors including findings from the vasal fluid, time since vasectomy, and surgeon skill level. Few papers have examined this decision-making algorithm since the landmark paper by the Vasovasostomy study group in 1991. While most microsurgeons prefer VV to VE due to increased patency and pregnancy rates, the need to perform a VE is generally encouraged when pasty fluid or no sperm parts are found in the vas at the time of reversal. These findings are interesting and are another important addition to the literature. Unfortunately, despite the authors’ efforts, relatively few predictive factors were found. Their findings do somewhat parallel those published by the Vasovasostomy study group, wherein the Silber grading system appears to correlate with pregnancy rates. The authors identified sperm heads only (Silber 4) or no sperm (Silber 5) as negative predictors with motile sperm (Silber 1) almost achieving statistical significance as a positive factor.(Reviewer–Charles Welliver, MD).